- Assesses anxiety and depression in a non-psychiatric population
- Has 2 subscales: Depression and Anxiety, both with 7 items
- Other than physically ill individuals, the HADS is also used with community samples/populations
Clinical Considerations
- It is unclear if the few somatic items influence the reliability and validity of this measure with an SCI population. Further research is needed to confirm psychometric properties within this population.
- The HADS should only be used as a screening instrument. It is one of two instruments with an anxiety-specific scale that has had its measurement properties evaluated for the SCI population.
ICF Domain
Body Function ▶ Mental Function
Administration
- Self-report format
- Responses are based on the relative frequency of symptoms over the past week, using a four point Likert scale ranging from 0 (not at all) to 3 (very often indeed)
- Can be completed in around 5 minutes
Number of Items
14
Equipment
None
Scoring
Responses are summed to provide separate scores for anxiety and depression symptomology; each of anxiety or depression scale have a score range of 0-21.
Languages
Versions of the scale are available in English, Arabic, Dutch, French, German, Hebrew, Swedish, Italian, Spanish, and many others (not all translations are validated).
Training Required
None
Availability
The Hospital Anxiety and Depression Scale worksheet can be purchased here.
# of studies reporting psychometric properties: 9
Interpretability
- Higher scores indicate greater likelihood of depression or anxiety
- Normative values: Anxiety = 6.9 (4.2); Depression = 5.5 (3.7); Total = 12.3 (7.1)
(Woolrich et al. 2006: n=963, 780 males, 183 females; tetraplegia and paraplegia; mean time since injury = 19.5 years) - A cut-off point of 8/21 for the Anxiety subscale gave a specificity of 0.78 and sensitivity of 0.9; a cut-off point of 8/21 for the Depression subscale gave a specificity of 0.79 and a sensitivity of 0.83.
MCID: not established in SCI
SEM: not established in SCI
MDC: not established in SCI
Reliability
- Internal consistency of the Anxiety subscale of the HADS is High (Cronbach’s a = 0.846-0.85)
- Internal consistency of the Depression subscale of the HADS is High (Cronbach’s a = 0.79-0.81)
(Berry & Kennedy 2003: n=43 SCI in-patients, 38 males, 5 females; 13.9% complete tetraplegia, 37.2% incomplete tetraplegia, 23.3% complete paraplegia, 25.6% incomplete paraplegia)
(Woolrich et al. 2006: n=963, 780 males, 183 females; tetraplegia and paraplegia; mean time since injury = 19.5 years)
Validity
- Correlation of the total HADS scale is Moderate with the:
- Life Satisfaction Questionnaire (Pearson’s r = -0.585)
- Sexual Adjustment Scale (Pearson’s r = -0.49)
- Emotional Quality of the Relationship scale (-0.38)
- Correlation of the Anxiety subscale of the HADS is Moderate with the:
- Spinal Cord Lesion Coping Strategies – Acceptance subscale (Pearson’s r = -0.45)
- Spinal Cord Lesion Coping Strategies – Fighting Spirit subscale (Pearson’s r = -0.40)
- SF-36 mental component summary (Pearson’s r = -0.44)
- Moorong Self-Efficacy Scale (MSES) (Pearson’s r = -0.315)
- Correlation of the Depression subscale of the HADS is Moderate with the:
- Spinal Cord Lesion Coping Strategies – Acceptance subscale (Pearson’s r = -0.58)
- Spinal Cord Lesion Coping Strategies –Fighting Spirit subscale (Pearson’s r = -0.49)
- SF-36 physical component summary (Pearson’s r = -0.37)
- Moorong Self-Efficacy Scale (MSES) (Pearson’s r = -0.56)
(Berry & Kennedy 2003: n=43 SCI in-patients, 38 males, 5 females; 13.9% complete tetraplegia, 37.2% incomplete tetraplegia, 23.3% complete paraplegia, 25.6% incomplete paraplegia)
(Ebrahimzadeh et al. 2014; n=52; 52 males; paraplegia and tetraplegia; mean time since injury: ~30 years, war veterans with SCI)
(Elfstrom et al. 2007: n=355; 279 males, 74 females; injury level: cervical- sacral; 162 complete paraplegia, 85 complete tetraplegia, 32 incomplete paraplegia, 58 incomplete tetraplegia, 18 missing information; mean age: 49 years; mean age at injury; 27.8 years)
(Kreuter et al. 1996: n=75, 64 males, 11 females; tetraplegia and paraplegia)
(Munce et al. 2016; n=99; traumatic SCI; outpatient; mean (SD) time since injury: 17.5 (12.3) years)
(Woolrich et al. 2006: n=963, 780 males, 183 females; tetraplegia and paraplegia; mean time since injury = 19.5 years)
Responsiveness
No values were reported for the responsiveness of the HADS for the SCI population.
Floor/Ceiling Effect
No values were reported for the presence of floor/ceiling effects in the HADS for the SCI population.
Reviewers
Jane Hsieh, Tyra Chu, Elsa Sun
Date Last Updated
31 December 2024
Berry C, Kennedy P. A psychometric analysis of the Needs Assessment Checklist (NAC). Spinal Cord, 2002; 41: 490-501.
http://www.ncbi.nlm.nih.gov/pubmed/12934089
Ebrahimzadeh MH, Soltani-moghaddas SH, Birjandinejad A, Omidi-kashani F, Bozorgnia S. Quality of life among veterans with chronic spinal cord injury and related variables. Arch Trauma Res. 2014;3(2):e17917.
http://www.ncbi.nlm.nih.gov/pubmed/25147777
Elfstrom ML, Kennedy P, Lude P, Taylor N. Condition-related coping strategies in persons with spinal cord injury: a cross-national validation of the Spinal Cord Lesion-related Coping Strategies Questionnaire in four community samples. Spinal Cord, 2007; 45: 420-428.
http://www.ncbi.nlm.nih.gov/pubmed/17179976
Gounelle M, Cousson-Gelie F, Nicolas B, Kerdraon J, Gault D, Tournebise H, et al. Frenck cross-cultural adaptation and validity of the Moorong Self-Efficacy scale: the MSES-FR, a measure of Self-Efficacy for French people with spinal cord injury. Disabil Rehabil. 2022. 44(25):8066-8074
https://pubmed.ncbi.nlm.nih.gov/34802337/
Kreuter M, Sullivan M, Siosteen A. Sexual adjustment and quality of relationships in spinal paraplegia: A controlled study. Arch Phys Med Rehabil 1996;77:541-548.
http://www.ncbi.nlm.nih.gov/pubmed/8831469
Mangold J, Divanoglou A, Middleton J, Jörgensen. The Swedish version of the Moorong Self-Efficacy Scale (s-MSES) – translation process and psychometric properties in a community setting. Spinal Cord. 2024; 62(2):71-78
https://pubmed.ncbi.nlm.nih.gov/38172426/
Middleton JW, Tate RL, Geraghty TJ. Self-Efficacy and Spinal Cord Injury: Psychometric Properties of a New Scale. Rehabil Psychol. 2003; 48(4):281-288
http://dx.doi.org/10.1037/0090-5550.48.4.281
Munce SE, Straus SE, Fehlings MG, et al. Impact of psychological characteristics in self-management in individuals with traumatic spinal cord injury. Spinal Cord. 2016;54(1):29-33.
http://www.ncbi.nlm.nih.gov/pubmed/26055818
Menon N, Gupta A, Khanna M, Taly AB, Thennarasu K. Prevalence of depression, fatigue, and sleep disturbances in patients with myelopathy: Their relation with functional and neurological recovery. J Spinal Cord Med. 2016.
http://www.ncbi.nlm.nih.gov/pubmed/25582227
Paker N, Bugdayci D, Midik M, Celik B, Kesiktas N. Reliability of the Turkish version of the hospital anxiety and depression scale in the people with traumatic spinal cord injury. NeuroRehabilitation. 2013;33(2):337-41.
http://www.ncbi.nlm.nih.gov/pubmed/23949046
Snaith RP. The Hospital Anxiety And Depression Scale. Health and Quality of Life Outcomes, 2003; 1: 29.
http://www.ncbi.nlm.nih.gov/pubmed/12914662
Woolrich RA, Kennedy P, Tasiemski T. A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury. Psychol Health Med 2006; 11: 80–90.
http://www.ncbi.nlm.nih.gov/pubmed/17129897
Zigmond AS, Snaith RP. The Hospital Anxiety and Depression scale. Acta Psychiatr Scand 1983; 67: 361–370.
http://www.ncbi.nlm.nih.gov/pubmed/6880820
